Basic Information
| Provider Information | |||||||||
| NPI: | 1215935986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4176 | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703614176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858760300 | ||||||||
| FaxNumber: | 9858720317 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 TWIN OAKS DR | ||||||||
| Address2: | |||||||||
| City: | RACELAND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703942760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858374000 | ||||||||
| FaxNumber: | 9855374074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 11066R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 060048455 | 01 | LA | RR MEDICARE | OTHER | 1663522 | 05 | LA | MEDICAID |